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…and the winner is:

PRK, LASIK or SMILE ?

Omid Kermani MD, KölnAugenklinik am Neumarkt

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EOS - Egyptian Society Of Ophthalmlogy | Cairo | March 26./27. 2019

Indications

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Indications:

Myopia:

-0,25D to -8,0D

Astigmatism:

6.0D

Myopia:

-0,25D to -10,0D

Astigmatism:

6.0D

Hyperopia

+4,0D

Myopia:

-1,0D to -10,0D

Astigmatism:

6.0D

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Clinical Results

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Meta-Analysis

SMILE = LASIK

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Predictability SafetyEfficacy

Correction Of Astigmatism

° SMILE (Zeiss VisuMax)

• No torsion error control

• No Iris tracking

• No pupil centroid shift

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▪Signifikant undercorrection of refractive cylinder:

▪Astigmatismus < 2,50 D: 13% undercorrection per attempted D correction

▪Astigmatismus ≥ 2,50 dpt: 16% undercorrection per attempted D correction

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New Kids On The Block

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SCHWIND Femtosecond Laser

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First in Human Results (FiH)

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Complications

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• VA threatening

• Incidence 0,05 - 0,16%

• Days or years post-OP

• Therapy: CXL/ICR/PRK

• No restitutio ad integrum

Post-LASIK

Ectasia

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Advantage SMILE

° Vertical cuts (LASIK) destabilize more than horizontal cuts (SMILE)

° Anterior stroma is the stronger than posterior stroma

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Reinstein DZ et al. Small incision lenticule extraction (SMILE) history, fundamentals of a

new refractive surgery technique and clinical outcomes. Eye Vis (Lond) 2014;1:3

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Disadvantage SMILE

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Shajari M, Kolb CM, Mayer WJ, Vounotrypidis E, Steinwender G, KohnenT, Kook D. Comparison of changes in corneal

volume and corneal thickness after myopia correction between LASIK and SMILE. Submitted for publication

Higher tissue

consumption

for SMILE

compared to

LASIK

for the same

given ametropia !

SMILE & Ectasia ?

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„Normal Corneal Topography“ 27% of Ectasia CasesRandlemannJB et al.: Risk assessment for ectasia after corneal refractive surgery.

Ophthalmology 2008; 115:37-50

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LASIK & Trockenes Auge

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Epithelial Ingrowth

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° Influence of original flap creation method on incidence of

epithelial ingrowth after LASIK retreatment

• Letko E, Price MO, Price FW Jr

• Journal of Refractive Surgery (Thorofare, N.J. : 1995) [2009, 25(11):1039-1041]

• 272 LASIK retreatments ( 4 years period)

• 132 eyes MK-Flap & 140 eyes Femto-Flap

• Epi ingrowth in MK-Flap: 6,1%

• Epi ingrowth in Femto-Flap: 0,0%

Flap geometry ?

Incidence & Risk Factors

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Fs.-Laser vs. Mikrokeratom

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Epithelial Ingrowth

6,3% area of incision

0,3% centrally

SMILE

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D. Kook 2018

LASIK Flap Complications

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Flapfolds Flap displacement

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Capfolds

SMILE

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LASIK

° Buttonhole

° Irregular ablation

°DLK

SMILE

° Incomplete cut

° Incomplete lenticule

°DLK

Other Complications

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SMILE: Flat Learning Curve

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Complication rate: 26,9 % (43 of 160)

Femto LASIK

° PRK on top

° Flap lift

° Flap re-cut

SMILE

° Excimer Laser necessary !

° Flap cut on cap

° PRK on top

Retreatments

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What about PRK…is it out ?

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12 Monath Refractive Results

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Conclusion:VA rehabilitation faster post LASIK and less pain/discomfort. However, after 12 months the results do not show significantdifferences !

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Randomised

Controlled

One Eye PRK (n = 35)

One Eye SMILE (n = 35)

12 Monate

PRK vs.

ReLEx smile

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Conclusion:Refractive results and recovery are similar. Total HOA significantly higher after SMILE compared to PRK

TransPRK OZ and PTK Diameter

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Myopia Myopic Astigmatism Hyperopia Hyperopic Astigmatism MIxed Astigmatism

(WFO) OZ 6.0mm6.5mm7.0mm

6.0mm6.5mm7.0mm

6.0mm6.5mm7.0mm

6.0mm6.5mm7.0mm

6.0mm6.5mm7.0mm

EPI OZ = WFO OZ + 0.5mm

6.0mm => 6.5mm6.5mm => 7.0mm7.0mm => 7.5mm

= 8.0mm = 8.0mm = 8.0mm = 8.0mm

EPI Depth 45µm50µm55µm60µm65µm

45µm50µm55µm60µm65µm

45µm50µm55µm60µm65µm

45µm50µm55µm60µm65µm

45µm50µm55µm60µm65µm

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StreamLight® PRK By Wavelight

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° TouchFree

° Faster re-epitheliazation

° Less pain and discomfort

°On Top advantages:

• Flap & cap free (one procedure)

• No flap associated complications

• Less % Altered Tissue

• Less Risk of Ectasia

• Less cost of equipment

TransEpi PRK Advantages

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Indications:

Myopia:

-0,25D to -8,0D

Astigmatism:

6.0D

Myopia:

-0,25D to -10,0D

Astigmatism:

6.0D

Hyperopia

+4,0D

Myopia:

-1,0D to -10,0D

Astigmatism:

6.0D

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…and the winner is ?

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…the patient !

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Thank you !

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